Cooperstown Medical Transport
P.O. Box 202
Cooperstown, NY 13326
(607) 433-0000

Name

E-mail address

Address

City

State

Zip Code

Telephone #

Cell Phone #

Driver's License #

EMT Cert #

Level

List any moving violation convictions within the past 5 years

Date first available to start work

Desired salary

Have you ever been convicted of a crime?

  If Yes, then please describe the nature of the offense, when, where, and the disposition of the conviction

Have you ever been employed here before?

If Yes, then please list dates of employment and reason for leaving

Have you ever submitted an application here before?

If Yes, when

How did you learn about our service?

Please list any friends or relatives currently employed by CMT

Please list most recent employer first, along with a 5-year employment history in order of employment.

Present or most recent employer

Name, address and phone number of employer

Immediate supervisor

Can we contact your supervisor?

Describe duties or positions held

Dates of employment

Salary

Reason for leaving

Other employment (same questions)

Highest level of education?

List names of schools attended, course of study, and degree / diploma / certificates received

Training history: instructor, course location, certification level, date of course

Volunteer Service: Please list any current or previous volunteer service

Please list name, address and phone number of three (3) personal references

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorized investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from the utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative."